Evaluation of Kangaroo Mother Care Services in Uganda
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FINAL EVALUATION OF KANGAROO MOTHER CARE SERVICES IN UGANDA April 2012 Report compiled by Anne-Marie Bergh 1, Karen Davy 1, Christine Dorothy Otai 2, Agnes Kirikumwino Nalongo 3, Namaala Hanifah Sengendo 4, Patrick Aliganyira 4 1 MRC Unit for Maternal and Infant Health Care Strategies, University of Pretoria, South Africa 2 Kiwoko Hospital, Naseke District, Uganda 3 Mulago Hospital, Kampala, Uganda 4 Save the Children in Uganda FINAL Save the Children is the leading independent organization for children in need, with programs in 120 countries. We aim to inspire breakthroughs in the way the world treats children, and to achieve immediate and lasting change in their lives by improving their health, education and economic opportunities. In times of acute crisis, we mobilize rapid assistance to help children recover from the effects of war, conflict and natural disasters. Save the Children's Saving Newborn Lives program, supported by the Bill & Melinda Gates Foundation, works in partnership with countries in Africa, Asia and Latin America to reduce newborn mortality and improve newborn health. For more information visit www.savethechildren.org. The Maternal and Child Health Integrated Program (MCHIP) is the USAID Bureau for Global Health's flagship maternal and child health program (MCHIP). MCHIP supports programming in maternal, newborn and child health, immunization, family planning, malaria, nutrition and HIV/AIDS, and strongly encourages opportunities for integration. Cross-cutting technical areas include water, sanitation, hygiene, urban health and health systems strengthening. Visit www.mchip.net<http://www.mchip.net/> to learn more. Pictures in this report were taken by Anne-Marie Bergh and Karen Davy FINAL TABLE OF CONTENTS Assessors v Reviewers vi Acknowledgements vi Acronyms vii 1. GENERAL BACKGROUND 1 2. BACKGROUND TO UGANDA AND ITS HEALTH SERVICES 1 3. KANGAROO MOTHER CARE IN UGANDA 2 4. METHODOLOGY 6 4.1 Scope and objectives of current evaluation 6 4.2 Evaluation approach 6 4.3 Conceptualisation of kangaroo mother care 7 4.4 A stages-of-change model 8 4.5 Sampling 9 4.6 Preparation for evaluation 10 4.7 Format of an evaluation visit 11 4.8 Limitations of the study 11 5. MAIN FINDINGS 11 5.1 Scaling up of KMC services by facility numbers 12 5.2 Progress with KMC implementation 14 5.3 Resources for implementation 15 5.4 KMC services, facilities and practices 17 5.4.1 Newborn services provided by facilities 17 5.4.2 History of KMC implementation 18 5.4.3 KMC facilities 18 5.4.4 KMC practice 19 5.4.5 KMC position (skin-to-skin care) 20 5.4.6 KMC nutrition and weight monitoring 21 5.4.7 KMC documentation and recordkeeping 22 5.4.8 KMC staff 23 5.4.9 Discharge and follow-up 24 5.4.10 Client satisfaction 25 5.4.11 Community sensitisation and involvement 26 6. MAIN CONCLUSIONS 29 6.1 KMC implementation 29 6.2 KMC practice 31 6.3 Documentation, record keeping, data management and reporting mechanisms 31 7. KEY RECOMMENDATIONS 32 7.1 From central to district level 32 7.2 Newborn programs 32 7.3 Facility level 32 7.4 KMC practice 33 7.5 Further points for investigation 33 References 33 i FINAL List of tables Table 1. Kangaroo mother care included in the Standards for Newborn Health Care Services 3 Table 2. Scoring of facilities 10 Table 3. Refinement of the breakdown of progress scores 10 Table 4. Coverage of newborn care projects in Uganda 14 Table 5. Facility scores and interpretation of the scores 15 Table 6. Overview of support with equipment and materials 17 Table 7. Staff training in hospitals visited 24 Table 8. Summary of implementation progress per progress marker 28 List of figures Figure 1. The components of kangaroo mother care 8 Figure 2. Stages of progress in implementation 9 Figure 3. Map with distribution of facilities visited 11 Figure 4. Plotting of hospitals according to score 16 Appendices The following appendices are available on request: Appendix A Permission letter of Uganda Ministry of Health Appendix B Johns Hopkins IRB letter Appendix C Written consent signed by the head of facility Appendix D Verbal consent from key informant(s) Appendix E Consent from mothers for taking photographs of them and their babies Appendix F Feedback report form Appendix G District guidelines for preparation for facility visits Appendix H Presentation prepared for feedback to stakeholders at the end of the monitoring process Appendix I Progress-monitoring tool ii FINAL EXECUTIVE SUMMARY Introduction Uganda has experience with the implementation of kangaroo mother care (KMC) since 1999 in the central/teaching hospital. After a slow start up to 2006, advocacy for KMC in keeping babies warm and promoting infant survival increased and newborn health (including KMC) became more prominent in the policy environment with the formation of the Newborn Steering Committee (NSC). This was followed by increased visibility for KMC in policy documents such as the Standards for Newborn Health Care Services (2010) and the Health Sector Strategic and Investment Plan (2010/11 – 2014/15). In 2012 Uganda was one of four countries selected for an in-depth evaluation, using standard measurement tools, to systematically measure the scope and institutionalisation of KMC services and describe the barriers and facilitators to sustainable implementation. Methodology A convenience sample of 11 health care facilities was selected, including one central, one regional, 4 district and 3 private, not-for-profit hospitals, plus 2 health centres IV. The facilities were visited by two teams of locally trained assessors under the guidance of a consultant. The teams interviewed key informants and KMC focal persons and observed the KMC services. Results were interpreted by means of a model with six stages of change. Facilities received a score out of 30. Facilities scoring above 10 out of 30 demonstrate implementation of KMC or evidence of KMC practice; those scoring above 17 out of 30 demonstrate the integration of KMC into routine practice; and those with more than 24 out of 30 show sustainable KMC practice. Results The 11 health care facilities achieved implementation scores ranging between 8.28 and 21.72 out of the possible 30 points, with an average score of 14.45. Two facilities were still on the level of preparing for KMC implementation. Eight facilities were at the level of implementing KMC, whereas one facility demonstrated some evidence of integrating KMC into routine practice. No facilities have yet demonstrated sustainable practice. KMC facilities. One hospital had been designated as “Baby-Friendly” around 2005, with 2 more assessed but not having received the results yet. In all facilities, except the central and regional hospitals, KMC was part of the maternity unit and linked to care in the postnatal ward. Four facilities had a separate room for KMC, one had a special corner in the postnatal ward and one used curtains to create a KMC space in a corridor. The number of dedicated beds ranged between 1 and 6 and the environment ranged from pleasant to cramped or looking unattractive. Public hospitals did not provide food for mothers. Almost all facilities had educational materials available in the form of posters provided by donors or posters staff at the facilities created themselves. Only 3 facilities indicated that KMC education was included in antenatal care. Types of KMC practised. There still appears to be many missed opportunities where both intermittent and continuous KMC are not practised optimally. According to self-reports by facility staff, 6 hospitals practised intermittent KMC, but only 2 could provide any records to iii FINAL verify it. Although 8 facilities claimed to practise continuous KMC, only 3 facilities followed the principle of having the baby in the skin-to-skin position for at least 20 hours per day. Decisions regarding babies’ readiness for KMC were made by the doctor in one facility and by nurses in 3 facilities. Seven facilities indicated that it was a joint decision between nurses and doctors. Babies were observed in the KMC position in 6 facilities. Local cloth was mostly used for tying the baby. Three facilities allowed a guardian or companion (mostly only one guardian at a time) to be with the mother any time of the day and 2 facilities did not allow them at all. Where companions were allowed they played an important role in the psychological support of the mother and assisting with daily chores, such as washing clothes, and preparing and supplying meals. Record keeping and documentation. Six hospitals had a written feeding policy, whereas 3 hospitals had a job aid for calculating volumes of feeds displayed on the wall. Only 3 facilities recorded each feed a baby received. Seven facilities weighed babies regularly. Weights were reported to be recorded on a variety of documents, including nursing and doctors’ notes, the baby’s file (e.g. observation charts), the mother’s chart, the KMC register and the discharge form. Nine facilities had some form of keeping records for KMC babies – 7 with a special register or collective record and 4 with doctors’ daily notes. According to the assessors, one hospital had good quality data in their records, whereas it was poor in 4 facilities. Two facilities had guidelines for the practice of KMC. The gaps with regard to documentation and record keeping made it impossible to assess the extent and quality of KMC practice in most of the facilities. Because none of the facilities could provide evidence of the survival rates before and after the introduction of KMC, the effect of the introduction of KMC on neonatal mortality could not be assessed. Discharge and follow-up. In 8 hospitals doctors decided when a baby was ready for discharge (in 7 with input from nurses) and in 3 facilities nurses were the primary decision makers.